Doctors finding ‘atypical overdoses’
At a time when drug overdoses are becoming more prevalent and lethal, a new report provides a snapshot of regional illicit drug use and, for the first time, highlights the complexity of detecting and treating patients at hospital emergency departments for a severe drug-related event.
The objective of CESAR’s Maryland Hospital Study, which began in 2016, was to identify illicit drugs that caused overdoses in patients at two hospital emergency departments in Maryland. Emergency physicians were dealing with a sudden rise in accidental drug overdoses and related deaths, thought to be linked to a group of designer drugs called synthetic cannabinoids.
One doctor described “atypical overdoses,” patients with breathing difficulties and constricted pupils who responded well to the opioid overdose-reversing drug naloxone, and then required sedation for acute agitation, violence and hyperactivity, all unrelated to opiate withdrawal. The physicians believed that knowing which drugs were in use might help tailor patient treatment.
A clearer picture
With an epidemic of drug overdoses continuing to grow, a new report from the University of Maryland has provided a picture of regional illicit drug use and, for the first time, highlights the complexity of detecting and treating patients at hospital emergency departments for a severe drug-related event. The objective of the study, which began in 2016, was to identify illicit drugs that caused overdoses in patients at two hospital emergency departments in Maryland.
Emergency physicians were battling a spike in accidental drug overdoses and related deaths, thought to be linked to a group of designer drugs called synthetic cannabinoids that mimic the chemicals in marijuana, known on the street as Spice or K2. One doctor described “atypical overdoses,” patients with breathing difficulties and constricted pupils who responded well to the opioid overdose-reversing drug naloxone, and then required sedation for acute agitation, violence and hyperactivity, all unrelated to opiate withdrawal.
At the same time, researchers at the Center for Substance Abuse Research (CESAR) at the University of Maryland, College Park, with the support of the U.S. Office of National Drug Control Policy, were generating a number of reports detailing illicit drug use patterns in criminal justice settings. The researchers used sophisticated analyses of de-identified urine samples to detect drugs.
The substance abuse researchers decided to expand their urine testing technique for the first time to hospital settings, and connect the test results to de-identified patient medical records. Hospitals typically use urine tests to detect just a handful of drugs and medical conditions.
The CESAR researchers enlisted the participation of emergency physicians at the University of Maryland Medical Center Midtown Campus (UMMC Midtown) in Baltimore, and the University of Maryland Prince George’s Hospital Center in Cheverly, a suburb of Washington, DC.
The urine specimens, 106 from Prince George’s and 69 from UMMC Midtown, were sent to the Armed Forces Medical Examiner System laboratory in Delaware where they were tested for 26 synthetic cannabinoids, 59 designer drugs and 84 other illicit and prescription drugs.
With the results, the researchers realized the mix of substances used by the emergency department overdose patients was much more complex than originally expected.
“We were thoroughly amazed that in a study where we thought everyone was having a synthetic cannabinoid-related problem, only one specimen tested positive for synthetic cannabinoids,” says principal investigator Eric Wish, Ph.D., director of CESAR at the University of Maryland, College Park, College of Behavioral & Social Sciences.
Wish says it was evident the street drugs had been re-engineered into new combinations that weren’t being detected. Another finding was a major disparity between the drugs patients said they had taken and physician suspicions of drug use, compared to the actual drugs detected.
Marijuana was the most common individual drug detected at both hospitals. Also, one-fifth to a third of the specimens at each hospital tested positive for a new psychoactive substance other than synthetic cannabinoids.
Most significantly, two-thirds of patients at both hospitals tested positive for multiple substances, and some specimens contained as many as six substances, which can potentially complicate the process of making an accurate overdose diagnosis.
Regional Drug Use Variations
In Baltimore, after marijuana, most of those studied tested positive for fentanyl, a highly potent synthetic opioid; in Prince George’s County, the drug detected was PCP, an illegal hallucinogenic drug that can trigger aggression and other behavior changes.
At UMMC Midtown, non-fentanyl opioids including morphine and codeine were found in 51 percent of urine samples, while 28 percent tested positive for fentanyl. Midtown emergency physician Zachary D.W. Dezman, M.D., says the deaths of nearly 700 people in Baltimore in 2017 were caused by opioids.
At UM Prince George’s, 47 percent of specimens had PCP and patients were three-to-four times more likely than those at Midtown to show “bizarre or aggressive behavior,” according to the physicians.
The study was not designed to analyze differences in fatality rates, but emergency physicians at both hospitals say anecdotal evidence indicates that, despite the constantly changing combinations of illicit drugs patients may ingest, treating the patient based on their symptoms seemed to work.
“These results suggest that supportive care is safe in patients suffering from acute intoxication from synthetic cannabinoids,” says Dezman, who is also an assistant professor of emergency medicine at the University of Maryland School of Medicine.
Adding fentanyl screening to the standard drug tests used in hospitals would be useful, Dezman says.